Anthem policy on propofol for colonoscopies may be shortsighted

There is perhaps no better metaphor for the painful relationship between patients and our for-profit healthcare system than the fact that Anthem Blue Cross thinks you don't need anesthesia for a colonoscopy.

It's not "medically necessary," the insurer says.

Anyone who has experienced this most invasive of medical procedures might think otherwise.

I spoke the other day with a fellow named Michael, who works locally in the TV industry but didn't want me using his full name because he's terrified that Anthem will retaliate by messing with his coverage (and it says a lot about our system that this is even a consideration).

Michael is in his 50s, so he's at that age when men are supposed to bow before the gods of gastroenterology.

His doctor has scheduled a colonoscopy in coming weeks, and Michael faces the prospect of paying hundreds of dollars out of pocket for anesthesia if he doesn't want to be awake for every excruciating moment of the exam.

Michael already knows what he'll do. He'll pay.

"I can't imagine going through that procedure without anesthesia," he told me.

Many, if not most, people would agree. There are certain experiences in life that you just don't want to be conscious for.

So Anthem's policy raises a number of questions. How do you define "medical necessity"? Does it apply only to life-or-death situations? Or does it also apply to making a patient more comfortable, or to making a very important preventive treatment more accessible to those with, shall we say, squeamish sensibilities?

At the same time, should Anthem be commended for trying to keep health-insurance costs down by limiting the treatments it will cover? Should other insurers follow the company's example?

Dr. Karen Sibert, a Los Angeles anesthesiologist, said that when a strong sedative is going to be used for a colonoscopy these days, the drug of choice is propofol, the same drug that played a role in Michael Jackson's death.

"Propofol sedation is lovely in the sense that you go to sleep quickly, wake up quickly and there's very little nausea," she said.

The thing is, propofol requires the presence of an anesthesiologist or a nurse-anesthetist, as opposed to milder sedatives that can be administered by a doctor or nurse. This can add as much as $500 to the cost of the procedure, which is what Anthem is trying to avoid.

Sibert said she can see the insurer's point. While propofol might make for a kinder and gentler colonoscopy, it's not always a necessity.

"I think we can all agree that luxury cars are wonderful, but an economy car can get the job done," Sibert said.

Some smaller insurers have followed Anthem's example. In 2008, Aetna said it too would limit coverage of propofol. However, backlash from doctors prompted Aetna to indefinitely delay that decision.

Gastroenterologists I spoke with said there's no question that propofol is preferred for colonoscopies.

Dr. Eric Esrailian, co-chief of the Division of Digestive Diseases at UCLA's David Geffen School of Medicine, said he'd use propofol for almost all colonoscopies if there were no other factors involved (read: if an insurance company wasn't second-guessing his decisions).

"Colon cancer is a preventable cancer," he said. "Screenings are the key. We should do whatever is necessary for society to be screened."

Colorectal cancers are the second-leading cause of cancer deaths in the United States, after lung cancer. The American Cancer Society estimates that more than 140,000 new cases are diagnosed annually.

While Anthem might be saving money by limiting use of propofol, it could be argued that the company is being shortsighted in its thinking.

Colonoscopies are intended to head off very costly ailments. Would it be cheaper over the long run for Anthem to make this test as easy and appealing as possible to the greatest number of people?

Leslie Porras, an Anthem spokeswoman, declined to answer that question.

But she said the company will cover anesthesia for colonoscopies "if it's deemed medically necessary by the physician, i.e. high risk."

Apparently that means that if a doctor makes a convincing case for propofol, the insurer will cave. Esrailian told me he's never been turned down by Anthem when he's insisted on propofol for a patient.

But other gastroenterologists have warned Anthem members that they may be in for considerable discomfort unless they're ready to pay their own way for propofol.

Alister George, medical director of the Digestive Health Center in Thousand Oaks, said in a letter to patients that if they're insured by Anthem, they're covered only for "moderate conscious sedation."

"At times the pain experienced while undergoing conscious sedation may be very unpleasant for some patients," he wrote. "The drugs used for conscious sedation may cause side effects such as prolonged drowsiness, low blood pressure, nausea and vomiting.

"Compared to propofol," George noted, "the recovery time for conscious sedation is considerably longer."

Dr. William Stuppy, a Los Angeles gastroenterologist, told me it's hard for him to imagine performing a colonoscopy these days without propofol.

"It makes the procedure easier on the patient and easier for me," he said.

UCLA's Esrailian said there's now discussion in the medical world of allowing gastroenterologists to administer propofol without the oversight of an anesthesiologist.

He noted that doctors are already giving patients relatively powerful painkillers such as Demerol if propofol isn't used.

I'm not qualified to say if loosening restrictions on propofol is the correct move. But Esrailian makes a good point: The goal should be to increase the number of people undergoing colonoscopies and getting a jump on potentially cancerous growths.

"This is such an important procedure," he said. "We really need to look at how we can get as many people as possible to have this procedure."

If an insurer is more interested in saving a buck than in preventing a cancer that kills more than 50,000 Americans every year, it seems that somebody's priorities are horribly out of whack.